Seizures: Recognition and Management for Students
Few calls make bystanders panic like a seizure. A person suddenly collapses, stiffens and starts jerking, and everyone around them is convinced they are dying. As a student, your job is the opposite of panic. Most seizures stop on their own, and the most useful things you can do are simple: protect the patient, time the seizure, look after the airway and find out why it happened. This guide explains what a seizure is, how to assess and support someone during and after one, and the red flags that mean something more serious is going on.
What a seizure actually is
A seizure is a burst of abnormal, excessive electrical activity in the brain. Neurons that normally fire in an organised way start firing together, and the result depends on which part of the brain is involved. If the activity spreads across both hemispheres, the patient loses consciousness and may have a generalised tonic clonic seizure. If it stays in one area, the patient may have a focal seizure, with twitching of one limb, strange sensations or a change in awareness without falling to the ground.
Epilepsy is a tendency to have recurrent, unprovoked seizures. Not every seizure means epilepsy. A seizure can be provoked by something else going wrong in the body, and that is why finding the cause matters as much as stopping the seizure.
Types you are likely to see
Generalised tonic clonic: sudden loss of consciousness, a stiff tonic phase, then rhythmic jerking of all limbs. Breathing may look ineffective and the patient may go grey or cyanosed.
Focal seizures: the patient may stay aware or have reduced awareness. You might see lip smacking, fumbling with clothes, staring or jerking of one side.
Absence seizures: brief episodes of staring and unresponsiveness, more common in children, often over in seconds.
Febrile seizures: seizures with a fever in young children, usually between about six months and five years of age. Most are brief, but the child still needs assessment for the cause of the fever.
Common causes
Always ask yourself why this person had a seizure today:
Known epilepsy, especially with missed medication, poor sleep, alcohol or illness.
Hypoglycaemia, which is quick to check and easy to miss.
Hypoxia from any cause, including cardiac arrest.
Head injury, recent or old.
Alcohol or benzodiazepine withdrawal.
Infection, including meningitis and encephalitis.
Drug toxicity or overdose.
Stroke or a brain tumour.
Eclampsia in a pregnant or recently pregnant woman.
Check a blood glucose level in every seizure patient. It takes seconds and the cause is completely reversible.
During the seizure
The priority is keeping the patient safe while the seizure runs its course:
Note the time it started. Duration drives your decisions.
Move hazards away from the patient rather than moving the patient, unless they are in danger.
Protect the head with something soft.
Do not restrain the patient and never put anything in their mouth.
Loosen tight clothing around the neck.
Give oxygen if the patient is hypoxic, according to your guidelines.
Watch what the seizure looks like, because the receiving team will want a description.
When a seizure will not stop
Most tonic clonic seizures stop within a couple of minutes. A seizure lasting five minutes or more, or repeated seizures without recovery in between, is treated as status epilepticus. The International League Against Epilepsy uses five minutes as the point where treatment should begin, because seizures that continue beyond this are less likely to stop on their own and more likely to cause harm.
Prolonged seizures cause hypoxia, acidosis, high temperature and, eventually, brain injury. Paramedics and emergency teams use benzodiazepines to stop prolonged seizures, given according to local clinical practice guidelines. As a student, your role is to recognise the time point early, prepare equipment and support the airway.
After the seizure
Once the jerking stops, the patient enters the postictal phase. They are often drowsy, confused, agitated or exhausted, and they may have a headache or sore muscles. This phase can last minutes to hours.
Place the patient on their side once the seizure has finished to keep the airway clear.
Reassess airway, breathing and circulation, and suction if needed.
Check the blood glucose level and temperature.
Look for injuries, especially to the head, tongue and shoulders.
Assess the level of consciousness and watch for improvement over time.
Reassure the patient as they wake up, because confusion is frightening.
A patient who does not gradually improve after a seizure needs urgent thinking. Ongoing drowsiness may mean a subtle continuing seizure, a head injury, hypoglycaemia, an overdose or a stroke.
Taking the history
Much of your history will come from witnesses, so ask them before they leave:
What happened just before? Did they look pale, complain of feeling unwell or hit their head?
What did the seizure look like, and how long did it last?
Has this happened before? Do they have epilepsy, and have they taken their medication?
Any alcohol, drugs, recent illness, headache or fever?
Could they be pregnant or recently have given birth?
Seizure mimics
Not everything that jerks is a seizure. Simple fainting can cause a few brief jerks, known as convulsive syncope, but the patient usually recovers quickly without a long period of confusion. Rigors from fever, psychogenic non epileptic seizures, low blood sugar and cardiac arrhythmias can all look similar. A seizure with no clear history in an older patient should always make you think about the heart.
Red flags
First ever seizure.
A seizure lasting five minutes or more, or clusters without recovery.
Failure to return to normal.
Head injury, fever, neck stiffness or a new severe headache.
Pregnancy or the weeks after birth.
Injury during the seizure.
A seizure in water or with signs of aspiration.
Common student mistakes
Not timing the seizure.
Trying to hold the patient down or put something in their mouth.
Forgetting the blood glucose level.
Assuming a known epileptic patient has no other cause.
Leaving a postictal patient on their back.
Losing the witnesses before getting a description.
Conclusion
Seizures look dramatic, but the approach is calm and systematic: keep the patient safe, time the seizure, support the airway, check the blood glucose level and look for the cause. Know that five minutes is the point where a seizure becomes an emergency in its own right, and remember that a patient who does not wake up properly afterwards is telling you something else may be wrong.
References
Fisher RS, Cross JH, French JA, et al. Operational classification of seizure types by the International League Against Epilepsy. Epilepsia. 2017;58(4):522.
Trinka E, Cock H, Hesdorffer D, et al. A definition and classification of status epilepticus. Report of the ILAE Task Force on Classification of Status Epilepticus. Epilepsia. 2015;56(10):1515.
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Disclaimer: This article is general education for students. It is not medical advice, and it does not replace your service's clinical practice guidelines, your educators or your local protocols.
